Peroneus Quartus Muscle As Cause Of Chronic Lateral Ankle Pain

Peroneus
Quartus Muscle As Cause Of Chronic Lateral Ankle Pain By A Female Professional Ballet Dancer
Case Report
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Patrick Vienne, Tobias Wyss
Department of Orthopaedics, University of Zurich, Balgrist, Switzerland
Peroneus Quartus Muscle As Cause Of Chronic
Lateral Ankle Pain By A Female Professional
Ballet Dancer: A Case Report
Zusammenfassung
Résumé
Musculus peroneus quartus als Ursache eines retromalleolären
Impingements bei einer Ballett-Profitänzerin: Fallbeschreibung.
Der Musculus peroneus quartus wurde erstmals 1816 von Otto beschrieben. Es handelt sich um einen akzessorischen Muskel, welcher seinen Ursprung auf dem Muskelbauch des Peroneus brevis
hat und am lateralen Calcaneusrand inseriert. Seine Sehne kann
einen retromalleolären Konflikt auslösen. Wir beschreiben diesen
Fall bei einer professionellen Ballett-Tänzerin.
Fallbeschreibung: Die 20-jährige Ballett-Tänzerin klagte über belastungsabhängige Beschwerden retromalleolär lateral besonders
bei Landungen in den Stellungen «pointes» oder «demi-pointes»
in maximaler Plantarflexion des oberen Sprunggelenkes. Bei der
klinischen Untersuchung, Druckdolenz am lateralen Calcaneus
und diskrete Schwellung infra- und retromalleolär. Eine probatorische und therapeutische Lokalinfiltration mit Cortison konnte den
Zustand momentan deutlich verbessern. Beim Wiederauftreten der
Beschwerden und bei entsprechender funktioneller Behinderung
wurde eine chirurgische Behandlung beschlossen.
Wir fanden einen retromalleolären Konflikt am Insertionsort der
Sehne des M. peroneus quartus am Calcaneus. Die Sehne wurde
reseziert, und der N. suralis wurde nach lateral subkutan verlagert.
Der postoperativer Verlauf war komplikationslos. Nach 2 Wochen
Teilbelastung im OSG-Scotch-Cast konnten die Belastungen im
Wasser progressiv gesteigert werden. Eine Vollbelastung wurde
nach 6 Wochen erlaubt. Die Tänzerin konnte dann an der Barre
trainieren, nach 6 Monaten war sie in ihrem Sport wieder voll im
Einsatz und beschwerdefrei.
Die Sehne des M. peroneus quartus kann einen retromalleolären
Konflikt verursachen. Bei chronischen therapieresistenten Beschwerden in maximaler Plantarflexion des OSGs soll man an
diese Differentialdiagnose denken. Durch chirurgische Exzision
der Sehne konnte in diesem Fall ein optimales Resultat erreicht
werden.
Muscle peroneus quartus comme cause de conflit rétromalléolaire
externe chez une danseuse de ballet professionnelle: exemple de
cas et revue de littérature
Le muscle peroneus quartus a été décrit pour la première fois par
Otto en 1816. Il s’agit d’un muscle accessoire de la jambe ayant
pour origine le corps musculaire du court péronier et pour insertion le bord latéral du calcanéum. Son tendon peut être à l’origine
d’un conflit rétromalléolaire externe. Il s’agit là, à notre connaissance, du premier cas d’un tel conflit publié chez une danseuse
professionnelle.
Description du cas: Il s’agit d’une jeune danseuse professionnelle
de 20 ans souffrant de douleurs rétromalléolaires externes principalement à l’effort et lors de réception de sauts sur pointes et demipointes, en flexion plantaire maximale de la cheville. A l’examen
clinique, douleur à la palpation du bord latéral du calcaneum,
rétromalléolaire et légère tuméfaction. Une infiltration locale de
corticostéroïdes a permis une nette amélioration, momentanée
toutefois. En raison de la persistance des douleurs et de la gêne
fonctionnelle, on se décide pour une exploration chirurgicale.
Résultats: Il s’agissait d’un conflit rétromalléolaire causé par le
tendon du péroneus quartus à son insertion sur le calcaneum. Le
tendon fut réséqué et le nerf sural transposé latéralement en souscutané. Les suites post-opératoires furent simples avec immobilisation par botte plâtrée amovible durant 15 jours et augmentation
progressive de la charge en piscine. A 6 semaines, charge totale
autorisée et reprise de la danse en piscine. A 3 mois, reprise de la
danse à la barre et en classe. A 6 mois, la patiente est asymptomatique et peut pratiquer son sport sans retenue.
Conclusion: Le tendon du muscle peroneus quartus peut causer
un conflit rétromalléolaire à l’origine de douleurs chroniques chez
le sportif. Il doit faire partie du diagnostic différentiel et un traitement agressif avec résection du tendon et transposition du nerf
sural permet d’obtenir un excellent résultat fonctionnel.
Schweizerische Zeitschrift für «Sportmedizin und Sporttraumatologie» 54 (1), 27–28, 2006
Introduction
The peroneus quartus muscle is an accessorius muscle of the lateral
compartment of the lower leg. The first description of this muscle
was done by Otto in 1816: «This muscle originates from the external surface of the lower third of the fibula and continues as a very
thin tendon up to the external surface of the calcaneus» [2]. Since
then a few other autors made a precise anatomical description
of this muscle and his different variations. Hecker [1] described
six types of variations and more recently, Sobel and coworkers
[3] diescribed eight types of variations and interestingly a simultaneous attrition of the peroneus brevis in the fibular groove in 18%
of the cases. The frequency of occurrence of this muscle varies
between 3% and 21.7% in the literature.
This muscle has more an anatomical interest for the surgeon and
very few cases are reported where this muscle could be the origin
of a chronic pain of the lateral ankle, producing a retromalleolar
conflict or lateral ankle stenosis with or without lesion of the
peroneus brevis muscle [4].
Case Report
We present the case of a 20 years old female professional dancer
who developed a chronic lateral ankle pain without any trauma
and without any particular increasing of her sport activities. The
pain occurred very progressively principally on the «pointes» and
«demi-pointes» position and by landing on the «demi-pointes»
and was essentially localized on the lateral aspect of the calcaneus, slightly retromalleolar and was only present by exercising
without persistance at rest. The patient did not note any swelling or local
redness and had no subjective instability or neurological symptoms.
Local physical therapy and strong reduction of training intensity could not influence the evolution of the pain. We saw the
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Vienne P. et al.
patient at our foot and ankle clinic about five months after onset of
the symptoms. The clinical examination showed local tenderness,
rather superficially retromalleolar on the calcaneus. There was no
redness or swelling at the examination. The patient presented a
slight Tinel phenomenon at the percussion of the sural nerve as a
sign of local irritation, but had clinically no subjective or objective
neurological deficit at the foot. The ankle joint was clinically stable
and the peronel tendons were not painful at the palpation and by
forced contraction. The pain could be reproduced by forced ankle
plantarflexion and digital pressure on the lateral calcaneus. There
was no strength deficit in comparison with the opposite side. The
x-ray of the hindfoot revealed no abnormality and a MRI examination could exclude a lesion or an inflammation of the peroneal
tendons. A CT-Scan could also exclude any bony modification like
bone bruise, fracture of the os trigonum or stress fracture of the
calcaneus.
Our first hypothesis was a local entrapment of the sural nerve
(calcaneal ast) so that we performed a local infiltration of the sural
nerve with 1 ml Scandicain 2% (Mepivacain) and 1 ml Kenacort
40 mg (Triamcinolone). This local infiltration gave a total pain
relief with return to full sport activities for about three weeks.
Then the pain returned at the same level than before the injection.
As the patient had to train hard to get a place in another company,
we decided to be more aggressive and went on for a local revision.
The sural nerve had no signs of constriction or inflammation, the
peroneal tendons were not inflammed, but we found a unique accessorius peroneus quartus tendon attaching directly on the lateral
calcaneus without any bony prominence about 2 cm proximally
of the insertion of the calcaneofibular ligament (Fig. 1). This thin
tendon was under tension particularly in neutral position of the
ankle and did clearly impinge posteriorly with the retinaculum of
the peroneal tendons in maximal plantar flexion and eversion of
the ankle. The entire tendon of this peroneus quartus muscle was
resected to the level of the superior border of the lateral calcaneus
(Fig. 2). The sural nerve was prepared and moved slightly distally
into the subcutaneous tissue. The peroneal tendons sheath was
closed with a Monocryl® 3.0 and the wound was closed in a usual
fashion. The histological examination of the resected tissue revealed skeletic muscle fibers with strong atrophic fibers and interstitial
fibrotic degeneration without inflammation signs.
The post-operative rehabilitation consisted of partial weight
bearing for the first two weeks, then progressive increase of the
sport activities, first in water then actively on the barre and return
to dance on the floor 6 weeks after surgery. The patient could progressively increase her activities, returned to her preoperative level
and remained nearly pain-free.
Discussion
The peroneus quartus muscle is an anatomical variation of the lateral hindfoot [3]. His frequency varies from 3% to 21.7% [3, 5] and
Figure 2: The tendon of the peroneus quartus was resected.
it can be involved as a source of pain in the lateral hindfoot area,
particularly in relation with a lesion of the peroneal brevis tendon [3]. Anatomically there are many descriptions of the various
insertion types of this accessorius muscle on the calcaneus and
the literature is very confusing. We did not find any report in the
literature where this muscle only could be at the origin of a chronic
lateral ankle pain without any lesion of the peroneal tendons, but
most probably by causing a local mechanical impingement. This
particular presentation by a professional female ballet dancer is
also due to the pattern of stresses on the ankle joint by «pointes»
and «demi-pointes» positions and by the extreme forces occuring
in the hindfoot by landing on «demi-pointes» position causing a
maximal active plantarflexion at the ankle joint. This particular
movement and the presence of this accessorius muscle on the lateral calcaneus can explain the local conflict and the pain created
by the chronic degeneration of the peroneus quartus tendon, as the
histological examination showed by our patient.
The differential diagnosis of chronic lateral ankle pain includes
intra- and extraarticular pathologies. The most common are chronic tendinitis of the peroneal tendons, chronic dislocation of the
peroneal tendon, chronic instability of the ankle and subtalar joint,
subtalar arthrosis, stress fracture of the calcaneus and of the os
trigonum and neurogenic pain produced by an entrapment of the
sural nerve and the calcaneal ast. In a population of sportive active patients and particularly when extreme ankle plantarflexion
movements are repeated, like in dancing and artistic gymnastics,
a possible impingement of the peroneus quartus tendon against
the peroneal tendon sheath as a cause of a chronic exercise related
pain of the lateral ankle joint should be excluded. Because it is a
mechanical conflict we think that the only effective treatment is the
resection of this degenerated accessorius tendon.
Korrespondenzadresse:
Dr. med. Patrick Vienne, Leiter Fuss-/Sprunggelenkschirurgie,
Orthopädische Universitätsklinik Balgrist, Forchstrasse 340,
CH-8008 Zürich, Tel. 01 386 12 77, Fax 01 386 12 79
E-Mail: [email protected]
References
Figure 1: Note the thin tendon of the peroneus quartus muscle on the lateral
border of the calcaneus.
1 Hecker P.: Etude sur le péronier du tarse: variations des péroniers
latéraux. Arch Anat Histol Embryol 3: 327, 1924.
2 Otto W.A.: Neue seltene Beobachtungen zur Anatomie, Physiologie
und Pathologie. Gehörig, p. 40, 1816.
3 Sobel M., Levy M.E., Bohne W.H.: Congenital variations of the peroneus quartus muscle: an anatomical study. Foot Ankle 2: 81–89, 1990.
4 Trono M., Tueche S., Quintart C., Libotte M., Baillon J.: Peroneus
quartus muscle : a case report and review of the literature. Foot Ankle
Int 20: 659–662, 1999.
5 Wood J.: Variations in human mycology observed during winter session of 1867–1868 at King’s College London. Proc R Soc 16: 438,
1868.